NHS Ten Year Plan review

After spending a little more time reflecting on the NHS 10 Year Plan and talking to various industry colleagues, I think the first thing we need to agree on is that it isn’t a plan, it’s a set of aspirations or intentions. I won’t push it to being objectives since much of it falls short of meeting SMART criteria for me.

The how we do it and what it takes to deliver it is more of the plan that many are looking for, and perhaps the biggest thing that is missing, particularly on the back of NHS England, the Commissioning Support Units (CSUs) and many Arm's Length Bodies (ALBs) being disbanded alongside digital being stripped out of Integrated Care Boards (ICBs). In many ways, it feels rushed, authored in silos and not built from the ground up. It’s very top-down down which can raise questions about how realistic it is to achieve. However, we have to start somewhere.

What it does is outline an ambitious vision for the future of healthcare in England, aiming to make it fit for the future. It focuses on three fundamental shifts: from hospital to community, from analogue to digital, and from sickness to prevention. 

What I want to do in this comprehensive review is explore its positives, areas of challenge, implications for patients and staff, the role of data, and the barriers and limitations to its implementation.

Positives of the NHS 10 Year Plan

The plan offers several commendable aspects that, if successfully implemented, could significantly improve healthcare delivery:

• Shift to prevention and community care: A major positive is the strong emphasis on shifting care away from hospitals and towards community settings, with a focus on preventing illness rather than just treating it. This includes earlier intervention, expanded primary care services, and neighbourhood health centres, making care more accessible and proactive.

• Empowering patients: The plan aims to give patients more control over their own health and care, with proposals for easier access to GPs, digital appointments, and access to personal health records. This fosters a more patient-centric approach.

• Harnessing technology and innovation: The commitment to a "digital by default" NHS is a significant step forward, but like with “digital first”, which has been around for years, we need to consider inclusion, accessibility and not believe a one-size-fits-all approach will work. This includes leveraging AI for staff, digital tools for patients (like the NHS App), and accelerating the adoption of home-based and personal health technologies. This has the potential to streamline processes, improve efficiency, and enhance patient experience, but as is already well-known, technology is only one element to successful transformation.

• Addressing health inequalities: The plan acknowledges the need to address disparities in health outcomes, aiming to ensure better care for all, regardless of location or socioeconomic status. Initiatives to reduce the "postcode lottery" for innovative health technologies are a welcome step.

• Workforce development: The plan outlines a vision for a better-treated, more motivated, and better-trained workforce. This includes personalised career development, overhauling education and training curricula, and a move towards reducing reliance on international recruitment and reduction in the use of agency staff.

• Focus on key health challenges: Specific commitments to improving outcomes in major health areas like cancer, mental health, heart disease, and maternity care are positive, with targets for earlier diagnosis and improved access to services. What has to be considered is the increased roles of charities and private healthcare providers and not just focus on the NHS as an isolated ecosystem.

• A single patient record: In principle, the ability to have a national patient record would have significant advantages both in terms of where patients could be treated, having all their information in one place and having something that encompassed a complete “cradle to grave” approach. Getting the architecture right and avoiding building in problems with inclusion and accessibility will be crucial, and if nothing else within the plan has it, then this needs to have true user centric design incorporated in it to avoid the mistakes of programmes like NPfIT.

Areas that could be challenged

Despite its positive aspirations, the plan faces significant challenges that could hinder its full realisation, a lot of which are “digital and data foundations” that we tend to ignore:

• Workforce shortages: While the plan sets out ambitions for workforce development, the current chronic staff shortages across the NHS remain a major concern. Delivering on increased training places and improved retention will require substantial, sustained effort and funding. The ambition to significantly reduce international recruitment by 2035 also presents a considerable challenge given current reliance.

• Funding and capital investment: The scale of transformation outlined in the plan requires substantial and sustained capital (and shift from capital to revenue) investment, particularly for digital infrastructure and community facilities. There are concerns that the funding allocated may not be sufficient to deliver the ambitious digital and infrastructure changes, especially for areas like outdated equipment and crumbling buildings.

• Digital infrastructure and interoperability: The vision of a "digital by default" NHS hinges on robust, integrated IT systems. The current landscape is fragmented, with variable digital and data maturity across organisations and significant interoperability challenges. Achieving seamless data sharing across primary, community, and secondary care and overcoming complex information governance procedures will be a monumental task. That has to include a specific strategy around managing obsolescence and legacy systems – many of which are not patient facing but have a massive impact on frontline care, e.g. rostering.

• Cybersecurity and resilience: There is very little included in the plan around developing a new operating model and associated infrastructure that is built from the ground up to be resilient and safe. Cybersecurity and resilience, including business continuity during the massive changes proposed, get very little attention.

• Cultural change and resistance to change: Shifting from a hospital-centric model to community-based and preventative care requires a fundamental cultural shift within the NHS and among patients. Staff may need to adapt to new ways of working, and patients may need to embrace digital channels and greater self-management. Resistance to these changes could be a significant barrier.

• Pace of implementation: The 10 year timeframe is ambitious, and delivering such widespread and fundamental changes at pace will be demanding. Past NHS reforms have often struggled with slow implementation and a lack of sustained focus e.g. NPfIT and shared care records.

• Public engagement and expectation management: Successfully shifting to a more proactive and digitally-enabled NHS requires public buy-in. Managing public expectations about how and where care is delivered, and ensuring equitable access to digital services for all demographics, will be crucial.

• Social care integration: While the plan focuses on health, the continuum of care with social care is critical. The plan's success will be limited if parallel improvements and integration with the often-underfunded social care sector are not achieved. If shared care records are ignored or disinvested in, then in at least the short term, we will see a breakdown in the care continuum to the detriment of people.

What it means for patients

For patients, the NHS 10 Year Plan promises:

• More accessible and convenient care: The shift to community care and digital access aims to make it easier to see a GP, access appointments (including digital and telephone consultations), and receive care closer to home. Neighbourhood health centres are central to this.

• Greater control and personalisation: Patients are expected to have more control over their health through access to their full records, personalised care plans (especially for those with complex needs), and the ability to manage appointments and prescriptions digitally.

• Earlier intervention and prevention: The focus on prevention means earlier detection of illness, proactive health advice, and support for healthier lifestyles, potentially leading to better long-term health outcomes and a reduction in serious illnesses.

• Targeted reduced waiting times: While a perpetual challenge, the plan aims to improve efficiency through digital transformation and shifts in care models, which ideally should contribute to reducing waiting lists for diagnosis and treatment.

• Faster access to innovation: The plan gives NICE more power to get new medicines and high-impact health technologies to patients faster, potentially reducing the "postcode lottery" for innovative treatments.

What it means for NHS staff

For NHS staff, the plan brings both opportunities and challenges:

• New roles and skills: The shift to community care and digital transformation will necessitate new roles, skills, and ways of working. Staff will need training and support to adapt to these changes, including becoming proficient in using new technologies like AI.

• Potential for reduced administrative burden: The "analogue to digital" shift aims to liberate staff from time-wasting administrative tasks, potentially improving productivity and allowing more time for direct patient care.

• Improved training and career development: The plan promises personalised career coaching, development plans, and an overhaul of education and training curricula, offering staff more opportunities for professional growth and skill acquisition.

• Initial workload pressures: While aiming for long-term benefits, the transition period may initially increase workload pressures as new systems are implemented, and staff adapt to new models of care.

• Focus on retention and wellbeing: The plan acknowledges the need to improve staff morale and retention, with ambitions to tackle high sickness rates and provide greater flexibility in working patterns.

• Increased domestic recruitment: The focus on training a homegrown workforce aims to reduce reliance on international recruitment, potentially creating more stable and predictable career paths for domestic healthcare professionals.

How data will help drive the changes proposed

Data is positioned as a critical enabler for the entire plan, driving changes in several ways:

• Personalised and proactive care: By linking and analysing patient data across different care settings (e.g., GP records, hospital admissions, community care), the NHS can gain a more holistic view of an individual's health. This allows for more personalised care plans, identification of at-risk individuals for proactive interventions, and tailored prevention strategies.

• Operational efficiency and planning: Real-time data on patient flow, demand for services, and resource utilisation will enable better operational planning, scheduling, and allocation of resources. This can help reduce bottlenecks, optimise bed management, and improve efficiency in areas like outpatient appointments.

• Performance monitoring and accountability: Comprehensive data collection and analysis will be crucial for monitoring the plan's progress against its targets, identifying areas of underperformance, and holding local systems accountable for delivering improved outcomes.

• Innovation and research: Access to large, anonymised datasets will be invaluable for research, identifying trends, developing new treatments, and evaluating the effectiveness of interventions and new technologies, including AI-driven solutions.

• Population health management: By aggregating data at a population level, the NHS can identify health inequalities, understand the prevalence of certain conditions in specific communities, and tailor public health interventions to address local needs. A neighbourhood health service is going to need reliable and local level analytics to support its effectiveness. With ICBs being stripped of digital capabilities and CSUs being done away with, it remains to be seen how this will be achieved.

• AI and automation: The plan envisions AI becoming a "trusted assistant" for staff. This will be powered by vast amounts of data, enabling AI to assist with diagnosis, administrative tasks, and even predicting patient needs. Everyone in the NHS already understands the state of data quality in so many systems, and without a clear strategy on addressing it, both from a legacy and ongoing perspective, having AI and automation that can be trusted and provide a “single version of the truth” will be limited.

Barriers to overcome or limitations to data-driven change

Despite the potential, significant barriers stand in the way of fully leveraging data:

• Paper: The ongoing prevalence of paper across the NHS means that having complete digital patient records is a long way off. Many Trusts are still storing millions of pieces of paper and still generating more than they scan, even when they have an electronic patient record. It isn’t simply the storage and management costs of this, but also the impact on productivity. Until this fundamental issue is dealt with a programme like “ban the fax”, the work developing and creating a single patient record will only ever deliver partial benefits.

• Data fragmentation and inconsistent infrastructure: Healthcare data is often stored in disparate systems across different organisations (GPs, hospitals, community trusts) with varying levels of digital maturity. Achieving seamless interoperability and a unified view of patient data is a monumental task.

• Data quality and standardisation: Data quality varies significantly across the NHS. Inconsistent data definitions, manual entry errors, and incomplete records limit the reliability and usability of data for analysis and decision-making. Standardisation of data capture and definitions is essential.

• Information governance and security: Robust information governance frameworks are crucial to ensure patient data is handled securely and ethically. Public trust in how their data is used is paramount, and any breaches or perceived misuse could severely undermine the plan's data ambitions. Balancing data sharing for benefit with privacy concerns is a delicate act.

• Workforce data literacy and skills: For data to drive change, staff across all levels of the NHS need to be data literate and possess the skills to interpret and act on insights derived from data. There's a need to build a dedicated data, digital, and technology workforce.

• Legacy systems and investment: The NHS is burdened by outdated legacy IT systems that are difficult to integrate. Replacing or upgrading these systems requires significant capital investment and time, which may not always be readily available.

• Procurement challenges: Navigating the technology market and procuring evidence-based, interoperable digital solutions can be challenging for individual NHS organisations. A more streamlined and coordinated procurement approach bringing together clinical, DDAT and procurement is needed along with some centralised management solutions (perhaps a form of passporting) making it easier for all types of vendors to engage with the NHS, rather than creating onerous barriers to entry which prevent SMEs, who often have the most novel technologies, being made available to the NHS.

• Ethical considerations of AI: As AI becomes more integrated, ethical considerations around bias in algorithms, transparency of decision-making, and accountability for AI-driven outcomes will need to be carefully addressed.

So, where does that leave us? 

As far as it goes, the NHS 10 Year Plan presents a bold and necessary vision for modernising healthcare in England. Its success hinges on overcoming deep-seated challenges related to getting the digital and data foundations in place, including workforce, funding, and particularly, the effective and ethical harnessing of data. The harsh reality is that we are way off in these areas. While the benefits for patients and staff are clear in theory, sustained political will, significant investment, and a committed, adaptable workforce will be crucial to translate these ambitions into tangible improvements in healthcare delivery. The devil will be in the delivery.

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